A Second Opinion on Patients Bearing Lists : New England Journal Article Argues Against Stereotyping the Symptom-Noters as Neurotics

Patients who go to their doctors' offices carrying lists of their symptoms and complaints aren't crazy, after all.

At least that's the thesis of an essay by an Alabama family practitioner in last week's New England Journal of Medicine, which published the article even though it lacks formal scientific research of the type normally found in the journal's pages.

The essay discussed the widely held assumption among physicians that they should beware of patients bearing lists because they might be mentally ill. In fact, the author contended, that stereotyped view could prompt doctors to overlook valid, accurate, painstakingly gathered information that can be of enormous assistance.

Unfortunate Tenacity

The conventional wisdom among physicians about list-writing patients got further confirmation in interviews with three Los Angeles family doctors, who said the belief survives with unfortunate tenacity in contemporary medicine. The local doctors included the chairman of the family practice department at the UCLA Medical Center, a past president of the Los Angeles County Medical Assn. and a Santa Monica family practitioner.

If this appears to laypersons to be a case of much ado about nothing, however, the publication of the essay by Dr. John F. Burnum marks what other physicians perceive as an important step in shaking an absurd bias that colors the way thousands of the nation's doctors relate to an important subgroup of their patients. Burnum has been in private practice in Tuscaloosa, Ala., for 30 years and teaches part time at the University of Alabama Medical School.

A Basic Tenet

Where this impression got its roots is not known for certain, and the list-writers-are-crazy topic is not the subject of formal lectures in medical schools. But the belief has, over time, emerged as a basic tenet of doctors' faith.

Dr. William Weil, a past president of the medical association, argued that the misperception of note-writers has potentially serious consequences because it destroys an often valuable means of communication between patient and doctor.

And if such communication is compromised, Weil argued, the successful treatment of the patient is placed seriously at risk.

Exploring the myth's origins, Burnum said he found that even among the writings of Sir William Osler, the physician widely perceived as one of the fathers of modern 20th-Century medical care, it is contended that a patient who comes to his doctor with a written list of things wrong with him probably suffers from a type of depression called neurasthenia. In one of the standard texts of medical practice, Burnum said, he found the argument that such note-writing "is almost a sure sign of psychoneurosis."

Burnum and other doctors noted that physicians are trained to believe that every patient should be able to describe what is wrong verbally without resorting to written materials. It has never been clear, according to this theory, why patients should be expected to have such complete, unprompted recall.

Among his colleagues, Burnum said in a telephone interview, he detected a pervasive, almost ridiculing, prejudice against note-writers. Burnum said he found nothing to corroborate the dictum and a great deal to contradict it.

"I don't think that teachers (in medical schools) stand up and give a formal lecture and warn students that patients who write lists may be crazy, but that's the general opinion that medicine has about this subject and it comes down from some of the saints of medicine," Burnum said.

To test his hypothesis of skepticism, Burnum conducted an admittedly informal study among his own patients. He found that, of 900 patients who arrived at his office over a three-month period, 72 brought lists with them. None of the male patients and only a few of the female patients had anything that even approached psychiatric symptoms and almost all of the emotionally normal list-bearers actually had serious physical disorders.

Best of Reasons

"Patients with organic disease, therefore," Burnum concluded, "do refer to notes to give the essence of their story--and not because they are peculiar or crazy." Burnum found many of the list-writers had the best of reasons for arriving at the doctor's office with a list.

"Businessmen, executives, teachers and professors make lists," Burnum said. "These people want to get things straight. They don't want to fool around with their time or their doctors' time."

Eight of the lists Burnum encountered had been drawn up by the patients' relatives and seven of the list-writers--all of them older patients--calmly explained that they kept lists because they realized their memories were not as clear as they once were and they wanted to make sure they didn't forget anything important. Most of the lists contained five or six items but one long one, with 20 entries, was prepared by a perfectly sane, emotionally stable business executive.